Objective Exploring the use of thromboelastography（TEG） to assess the risk of bleeding in patients with acute leukemia（AL）undergoing platelet transfusion refractoriness（PTR）. Methods To investigate the differences in TEG parameters between the PTR group and the non?PTR group in adult AL patients， and compare the differences in PLT and TEG parameters between the bleeding group and the non?bleeding group in the PTR group. Results A total of 58 AL patients were positive for platelet?related antibodies， and the proportion of PTR was 48.28%. A total of 20 patients with PTR were transfused with large?dose immunoglobulin， the effective rate was 40%， and 26 patients with PTR were transfused with matching platelets， the effective rate was 42.62%。 This study observed the difference of TEG parameters between the PTR group and the non?PTR group， and the results showed that there were no significant differences in PLT， R value， K value， α Angle and MA value before and after platelet transfusion in the PTR group. The PLT and MA values of the non?PTR group were significantly different before and after transfusion（P < 0.05）， while the R value， K value and α Angle were not significantly different. The PLT and MA values of the non?PTR group were significantly higher than those in PTR group after transfusion（P < 0.05）. Analysis and comparison of PLT and TEG parameters between the bleeding group and the non?bleeding group in patients with PTR showed that there was no significant difference in PLT value， R value， K value and α Angle of TEG， while MA value in the non?bleeding group was higher than that in the bleeding group， with significant difference（P < 0.05）. Conclusions Platelet count alone cannot accurately reflect the risk of bleeding in AL patients with PTR. TEG can effectively predict and evaluate the bleeding risk in AL patients， among which the maximum amplitude index has the most significant clinical significance， which is of great significance for disease evaluation and treatment guidance.